Hypertension is a major public health concern affecting over 1 billion people worldwide. It is a leading cause of death and its prevalence is increasing. The document discusses guidelines for defining and classifying hypertension from organizations like JNC and WHO. It also summarizes lifestyle modifications and pharmacological treatments recommended for managing hypertension, including initial drug classes like ACE inhibitors, ARBs, calcium channel blockers, and thiazides. The guidelines emphasize starting with one drug and titrating dosage before adding additional medications to control blood pressure.

1. Hypertension & It’s
Management– An Update
Courtesy by:
Presented by:
Md. Mahfuzul Islam
Executive
Medical Services Department
Opsonin Pharma Ltd

2. A SILENT
KILLER
HYPERTENSION

3. Hypertension is a silent, invisible killer that
rarely causes symptoms. Increasing public
awareness is key, as is access to early detection.
Raised blood pressure is a serious warning sign
that significant lifestyle changes are urgently
needed. People need to know why raised blood
pressure is dangerous, and how to take steps to
control it. Dr Margaret Chan

4. Hypertension is defined as a systolic
blood pressure equal to or above 140
mm Hg and/or diastolic blood pressure
equal to or above 90 mm Hg
4

5. The new Hypertension Guideline changes the
definition of hypertension, which is now considered
to be any systolic BP measurement of 130 mm Hg or
higher—or any diastolic BP measurement of 80 mm
Hg or higher.

6. CATEGORY
Optimal
Normal
Grade 1
SYSTOLIC
(mmHg)
<120
<130
140- 159
Grade 2 Hypertension 160- 179
Grade 3 Hypertension ("severe") >180
Isolated Systolic Hypertension >140
DIASTOLIC
(mmHG)
<80
<85
> 90-99
>100- 109
>110
<90
WHO/ISH CLASSIFICATION
OF BLOOD PRESSURE

7. Classification of Hypertension for Adult
JNC -8

9. Primary(Essential) Hypertension
- Elevated BPwithunknown
cause - 90%to 95%of all
cases
SecondaryHypertension
- Elevated BPwith aspecific
cause - 5%to 10%inadults

11. NON-MODIFIABLE
Age (> 55 for men; > 65 for women)
Gender
Family history
Ethnicity (African Americans)

12. a) Alcohol
b) Cigarette smoking
c) Diabetes mellitus
d) Elevated serum lipids
e) Excess dietary sodium
f) Obesity (BMI > 30)
g) Sedentary lifestyle
h) Socioeconomic status
i) Stress

13. Leading risk factor for global mortality

14. Frequently asymptomatic until severe and target
organ disease has occurred
Fatigue, reduced activity tolerance
Dizziness/Headache
Palpitations,
Angina
Dyspnoea

15. § Sleep apnea
§ Drug-induced or related causes
§ Chronic kidney disease
§ Primary aldosteronism
§ Renovascular disease
§ Chronic steroid therapy and Cushing’s syndrome
§ Pheochromocytoma
§ Coarctation of the aorta
§ Thyroid or parathyroid disease

16. The pathogenesis of
primary hypertensionisstill
unclear.
are many
associated
There
factors
withit.

17.  Genetic factors
 Sodium intake
 Renin- agiotensin
systems
 Sympathetic nervous
system
 Endothelial dysfunction
 Insulin resistance
 Other factors

18. Evaluate the patient
 History taking
 Physical examination
 Lab tests

19. History
 Family history
 Life style (exercise, salt intake, smoking, alcohol)
 Drug history
 Symptoms of secondary hypertension
(pheochromocytoma - paroxysmal headache, palpitation,
sweating )
 Symptoms of complication (angina, breathlessness)

20. Examination
 Radio-femoral delay in coarctation of aorta
 Enlarged kidneys in Polycystic kidney
disease
 Abdominal bruits in renal artery stenosis
 Characteristic face for Cushing's syndrome
 Abnormal optic fundi
 Apical heave(Left ventricular hypertrophy)
 Accentuation of the aortic component of the
second heart sound,
 Fourth heart sound
 Evidence of generalised atheroma or specific
complications, such as aortic aneurysm or
peripheral vascular disease.

22. TOD

23. Screening tests for identifiable
hypertension

24. Threshold of intervention:
 JNC-8: when should we initiate treatment:
 Age:>60years
 SBP≥150-mmHg
 DBP≥90-mmHg
 Age:<60years
 SBP≥140mmHg
 DBP≥90mmHg
 Strong recommendation to reduce stroke, heart failure ,
coronary heart disease.

25. Threshold of intervention:
 ASH guideline:
 Age:>80 years
 BP-150/90 mmHg
 Age<80 years
 BP-140/90 mmHg
 Uncomplicated stage-1 HTN
 Consider 6 -12 month lifestyle change before starting
pharmacotherapy.

26. Globally cardiovascular disease
accounts for approximately 17
million deaths a year, nearly one
third of the total deaths. Of these,
complications of hypertension
account for 9.4 million deaths
worldwide every year .
Hypertension is responsible for at
least 45% of deaths due to heart
disease and 51% of deaths due to
stroke .
26

27. In terms of attributable
deaths, hypertension is one of
the leading behavioral and
physiological risk factor to which
13% of global deaths are
attributed.
Hypertension is reported to
be the fourth contributor to
premature death in developed
countries and the
seventh in developing
countries.
27

28. Recent reports indicate that nearly
1 billion adults (more than a
quarter of the world’s population)
had hypertension in 2000, and
this is predicted to increase to
1.56 billion by 2025.
Today, mean blood pressure
remains very high in many African
and some European countries.
The prevalence of raised blood
pressure in 2008 was highest in
the WHO African Region at 36.8%
.
28

29. Hypertension (HTN) is a major public health concern, affecting 26%
of adults worldwide1
Number of
people with HTN
worldwide in 20001
972 million
Increase in the
number of adults with
HTN globally by 20251
60%
Percent of all global
healthcare spending
attributable to high
blood pressure2
10%
Annual worldwide cost of
hypertension2$370 billion
1. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005 Jan 15-21;365(9455):217-23. Gaziano TA, Asaf B, S Anand, et.al. The
global cost of nonoptimal blood pressure. J Hypertens 2009; 27(7): 1472-1477.
1.6 Billion
HTN patients estimated
by 2025

30. Global Burden of Hypertension
2025 Projection
26.4%of world adult
population had
hypertension
Total of 972 million
adults
establishedmarket
economies(eg, North
• Total of 1.56 billion adults
20 %in developed nations,
80% in developing nations)
Highest prevalence is in• Highest prevalence will be in
developingcontinents (eg, Asia,
Africa) will account for 75% of
world’s hypertensive patients
Year2000 Year2025
• 29.2%of world adult
population will have
hypertension
America, Europe)
Kearney PM et al. Lancet. 2005;365:217-223. 19

31. 31
 According to the Bangladesh NCD Risk Factor
Survey 2010, the prevalence of hypertension is
17.9% in general, 18.5% in men and 17.3% in
women
 A Systematic review reported that around 14%
Bangladeshi adults suffer from hypertension.
 A study in rural and semi urban surveillance sites
of icddr’b found the prevalence of hypertension to
be more than double that of in the semi-urban
population (24%) compared to the rural
population (11%)
Hypertension: Epidemiology in BD
Ref: BANGLADESH HEALTH WATCH REPORT 2016 Bangladesh Heart Journal Vol. 31, No. 2, July 2016

32.  In Bangladesh:
 WHO and BSM-NCD survey 2010-17.8%
 Hypertension center Rangpur: 33.3%
 Demographic reports: 24.4%
Hypertension: Epidemiology in BD
 According to the Health Bulletin 2015, CVD and stroke
together was the topmost cause of death in Upazila,
District and Medical College Hospitals, and was
responsible for 17.78%, 21.83% and 16.32% deaths
respectively in 2014.
Ref: BANGLADESH HEALTH WATCH REPORT 2016 Bangladesh Heart Journal Vol. 31, No. 2, July 2016

33. Prevalence of hypertension (blood pressure>140/90
mmHg or drug treatement) in urban and rural areas
in Bangladesh
Hypertension: Epidemiology in BD
BANGLADESH HEALTHWATCH REPORT 2016REf;

34. RULE OF HALVES
JAPI • VOL. 51 • FEBRUARY2003 22

35. Benefits of lowering BP

36. Management of Hypertension

37. Treatment of Hypertension:
Non pharmacological Pharmacological
Life style change Oral
Intravenous

38. Hypertension

39. 2013 ESH/ESC Guidelines for the management of arterial hypertension
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiolo
Powered by
gy (ESC) - J Hypertension 2013;31:1281-1357
Lifestyle changes for hypertensive patients
* Unless contraindicated. BMI, body mass index.
Recommendations to reduce BP and/or CV risk factors
Salt intake Restrict 5-6 g/day
Moderate alcohol intake Limit to 20-30 g/day men,
10-20 g/day women
Increase vegetable, fruit, low-fat dairy intake
BMI goal 25 kg/m2
Waist circumference goal Men: <102 cm (40 in.)*
Women: <88 cm (34 in.)*
Exercise goals ≥30 min/day, 5-7 days/week
(moderate, dynamic exercise)
Quit smoking

40. Patient education about treatment
Assess the patient’s understanding and acceptance of the
diagnosis of hypertension.
Discuss patient’s concerns, and clarify misunderstandings.
Tell the patient the blood pressure reading, and provide a
written copy.
Come to agreement with the patient on goal blood
pressure.
Ask the patient to rate from 1 to 10 his or her chance of
staying on treatment.

41. Patient education about treatment
Inform the patient about recommended treatment, and provide
specific written information about the role of lifestyle including diet,
physical activity, dietary supplements, and alcohol intake; use
standard brochures when Available
Elicit concerns and questions, and provide opportunities for the
patient to state specific behaviors to carry out treatment
recommendations.
Emphasize:
• Need to continue treatment
• Control does not mean cure
• One cannot tell if blood pressure is elevated by “feeling
or symptoms”; blood pressure must be measured

42. Non pharmacological

44. Treatment Regimen
Most of the patients need more than
one drug to achieve control of blood
pressure
Increase the dose of drug or add new
drugs at 2-4wks interval.
If the untreated blood pressure is
20/10mmHg above target blood
pressure, consider treatment
immediately with 2drugs.

45. JNC 8 Updates on Hypertension

46. JNC 8
• 2014 Evidence-Based Guidelines for
the Management of High Blood
Pressure in Adults
– JAMA. 2014;311(5):507-520
From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure
in Adults: Report From the Panel Members Appointed to the Eighth Joint National
Committee (JNC 8)
JAMA. 2014

47. JNC 8 Recommendations
• JNC7 published in 2003, IOM called for updated
guidelines in 2011 aimed at answering 3 major
questions:
– Does initiating antihypertensive treatment at specific BP
thresholds improve health outcomes?
– Does treatment with antihypertensive therapy to a specific BP
goal improve health outcomes?
– Are there differences in benefit/harm between antihypertensive
drugs or drug classes on specific health outcomes?
6 December 2016 Kovell LC et al. J Am Heart Assoc. 2015;4(12): e002315
James PA et al. JAMA. 2014;311:507–20

48. No
No
No
Black
JNC 8 Hypertension Guideline
Algorithm
Lifestyle changes:
• SmokingCessation
• Control blood glucose andlipids
• Diet
Eat healthy (i.e., DASHdiet)
Moderate alcoholconsumption
Reduce sodium intake to
no more than 2,400
mg/day
• Physical activity
Moderate-to-vigorous
activity 3-4 days a week
averaging 40 min persession.
Adult aged ≥ 18 years with HTN
Implement lifestyle modifications
Set BP goal, initiate BP-lowering medication based on algorithm
General Population
(no diabetes or CKD) Diabetes or CKD present
Age ≥ 60 years Age < 60 years All Ages
Diabetes
present No CKD
All Ages and Races
CKD present with
or without diabetes
BP Goal
< 150/90
BP Goal
< 140/90
BP Goal
< 140/90
BP Goal
< 140/90
Nonblack
Yes
Initiate thiazide or
CCB, alone or
combo
Initiate ACEI or
ARB, alone or
combo
w/another class
Reinforce lifestyle and adherence
Add a medication class not already selected (i.e. beta blocker, aldosterone antagonist, others) and titrate
above medications to max (see back of card)
Initiate thiazide, ACEI, ARB,
or CCB, alone or in combo
Reinforce lifestyle and adherence
Titrate meds to maximum doses, add another med and/or refer to hypertension specialist
Yes
Continue tx and monitoring
Initial Drugs of Choice forHypertension
• ACE inhibitor (ACEI)
• Angiotensin receptor blocker (ARB)
• Thiazide diuretic
• Calcium channel blocker(CCB)
At blood pressure goal?
At blood pressure goal?
Reinforce lifestyle and adherence
Titrate medications to maximum doses or consider adding another medication (ACEI, ARB, CCB, Thiazide)
At blood pressure goal?
Yes
Strategy Description
A Start one drug, titrate to maximum
dose, and then add a seconddrug.
B Start one drug, then add a second
drug before achieving max dose of
first
C Begin 2 drugs at same time, as
separate pills or combination pill.
Initial combination therapy is
recommended if BP is greaterthan
20/10mm Hg abovegoal
Reference: James PA, Ortiz E, et al. 2014 evidence-based guideline for the management
of high blood pressure in adults: (JNC8). JAMA. 2014 Feb 5;311(5):507-20
Card developed by Cole Glenn, Pharm.D. & James L Taylor, Pharm.D.

49. CompellingIndications
Hypertension Treatment
Beta-1 Selective Beta-blockers – possibly safer in patients
with COPD, asthma, diabetes, and peripheral vascular
disease:
• metoprolol
• bisoprolol
• betaxolol
• acebutolol
Indication TreatmentChoice
Heart Failure ACEI/ARB + BB + diuretic + spironolactone
Post –MI/ClinicalCAD ACEI/ARB AND BB
CAD ACEI, BB, diuretic, CCB
Diabetes ACEI/ARB, CCB, diuretic
CKD ACEI/ARB
Recurrent stroke prevention ACEI, diuretic
Pregnancy labetolol (first line), nifedipine, methyldopa
Drug Class Agents of Choice Comments
Diuretics HCTZ 12.5-50mg, chlorthalidone 12.5-25mg, indapamide 1.25-2.5mg
triamterene 100mg
K+ sparing – spironolactone 25-50mg, amiloride 5-10mg, triamterene
100mg
furosemide 20-80mg twice daily, torsemide10-40mg
Monitor for hypokalemia
Most SE are metabolic in nature
Most effective when combined w/ ACEI
Stronger clinical evidence w/chlorthalidone
Spironolactone - gynecomastia and hyperkalemia
Loop diuretics may be needed when GFR<40mL/min
ACEI/ARB ACEI: lisinopril, benazapril, fosinopril and quinapril 10-40mg, ramipril5-
10mg, trandolapril2-8mg
ARB: candesartan 8-32mg, valsartan 80-320mg, losartan 50-100mg,
olmesartan 20-40mg, telmisartan20-80mg
SE: Cough (ACEI only), angioedema (more with ACEI),
hyperkalemia
Losartan lowers uric acid levels; candesartanmay
prevent migraineheadaches
Beta-Blockers metoprolol succinate 50-100mg and tartrate 50-100mg twice daily,
nebivolol 5-10mg, propranolol 40-120mg twice daily, carvedilol 6.25-25mg
twice daily, bisoprolol 5-10mg, labetalol 100-300mg twice daily,
Not first line agents – reserve for post-MI/CHF
Cause fatigue and decreased heartrate
Adversely affect glucose; mask hypoglycemic awareness
Calciumchannel
blockers
Dihydropyridines: amlodipine 5-10mg, nifedipine ER 30-90mg,
Non-dihydropyridines: diltiazem ER 180-360 mg, verapamil 80-120mg 3
times daily or ER 240-480mg
Cause edema; dihydropyridines may be safely combined
w/ B-blocker
Non-dihydropyridines reduce heart rate andproteinuria
Vasodilators hydralazine 25-100mg twice daily, minoxidil5-10mg
terazosin 1-5mg, doxazosin 1-4mg given at bedtime
Hydralazine and minoxidil may cause reflex tachycardia
and fluid retention – usually require diuretic +B-blocker
Alpha-blockers may cause orthostatichypotension
Centrally-acting
Agents
clonidine 0.1-0.2mg twice daily, methyldopa 250-500mg twicedaily
guanfacine 1-3mg
Clonidine available in weekly patch formulation for
resistant hypertension

50. JNC 8: Graded Recommendations
A – Strong evidence
B – Moderate evidence
C – Weak evidence
D – Against
E – Expert Opinion
N – No recommendation

51. JNC 8: Drug Treatment
Thresholds and Goals
Based on trials HYVET,Syst-Eur,SHEP, JATOS,VALISH,andCARDIO-SIS
Recommendation 1
• Age > 60 yrs
– Systolic:
• Threshold > 150 mmHg
• Goal < 150 mmHg
– LOE: Grade A
– Diastolic:
• Threshold > 90 mmHg
• Goal < 90 mmHg
– LOE: Grade A

52. JNC 8: Drug Treatment
Thresholds and Goals
• Age < 60 yrs
- Diastolic:
• Threshold > 90 mmHg
• Goal < 90 mmHg
– LOE: Grade A for ages 40-59; Grade E for ages 18-
39
– Systolic:
• Threshold > 140 mmHg
• Goal < 140 mmHg
– LOE: Grade E
(Trials HDFP,Hypertension-StrokeCooperative,MRC,ANBP,and
VA Cooperative)
Recommendation 2
Recommendation 3

53. JNC 8: Drug Treatment
Thresholds and Goals
Recommendation 4 & 5
• Age > 18 yrs with CKD or DM
– Systolic:
• Threshold > 140 mmHg
• Goal < 140 mmHg
– LOE: Grade E
– Diastolic:
• Threshold > 90 mmHg
• Goal < 90 mmHg
– LOE: Grade E
Quality evidencefrom3trials(SHEP,Syst-Eur, and UKPDS)

54. JNC 8: Initial Drug Choice
• Nonblack, including DM
– Thiazide diuretic, CCB, ACEI, ARB
• LOE: Grade B
• Black, including DM
– Thiazide diuretic, CCB
• LOE: Grade B (Grade C for diabetics)
Recommendation 6
Recommendation 7
3 federally funded trials (VA Cooperative Trial, HDFP, and SHEP)

55. JNC 8: Initial Drug Choice
Recommendation 8
• Age > 18 yrs with CKD and HTN
(regardless of race or diabetes)
– Initial (or add-on) therapy should include
an ACEI or ARB to improve kidney
outcomes
• LOE: Grade B
– Blacks w/ or w/o proteinuria
• ACEI or ARB as initial therapy (LOE: Grade E)
– No evidence for RAS-blockers > 75 yo
• Diuretic is an option for initial therapy
From trial The AASK study

56. JNC 8: Subsequent Management
Recommendation 9
• Reassess treatment monthly
• Avoid ACEI/ARB combination
• Consider 2-drug initial therapy for
Stage 2 HTN (> 160/100)
• Goal BP not reached with 3 drugs, use
drugs from other classes
– LOE: Grade E

57. Summary Recommendations
6 December 2016 Kovell LC et al. J Am Heart Assoc. 2015;4(12): e002315

58. Summary Recommendations

59. Possible combinations of classes of antihypertensive drugs

60. Anti-hypertensive drugs and their usual dosage

61. Anti-hypertensive drugs and their usual dosage

62. Management of HTN in specific conditions

63. Pregnant women
•
•
•
•
If BP > 160/110 mmHg, treatment is
recommended (I, C).
Consider drug Rx (IIb, C)
– BP ≥150/95mmHg, or
– BP ≥140/90 mmHg + TOD
Methyldopa, labetolol, nifedipine preferred
(IIa, B)
Pre-eclampsia: IV labetolol or nitroprusside
(IIa, B)

64. DM
• Start drug Rx when SBP ≥140 mmHg (I, A).
• Target SBP < 140/90 mmHg (I, A).
• All classes of drugs are recommended and
can be used (I, A).
• RAS blockers preferred, especially if having
proteinuria / microalbuminuria (I, A).

65. HT with nephropathy
•
•
•
•
•
Target SBP < 140 mmHg (IIa, B).
RAS blockers indicated for HT with overt proteinuria
or microalbuminuria (I, A).
Recommend combining RAS blockers with other
anti-HT drugs to achieve target BP (I, A).
Combining two RAS blockers is not recommended
(III, A).
Aldosterone antagonists not recommened in CKD
(III, C).

66. Cerebrovascular disease

67. Atherosclerosis, arteriosclerosis, peripheral
artery disease
• Target BP < 140/90 mmHg.
• Carotid atherosclerosis: CCB, ACEI (IIa, B).
• PAD: BB may be considered. Their use does
not appear to be associated with worsening
of PAD symptoms (IIIb, A).

68. Resistant Hypertension
• Blood pressure remaining above goal (150/90 mm
Hg for the overall population and 140/90 mm Hg for
those with DM or CKD) in spite of concurrent use of
3 antihypertensive agents of different classes.
• Ideally, 1 of the 3 agents should be a diuretic & all
agents should be prescribed at optimal dose
amounts.
The JNC 7 report. JAMA 2003; 289: 2560-72.

69. Resistant HT
• MR antagonist, amiloride, doxazosin should
be considered.
• If drugs are ineffective: renal denervation and
baroreceptor stimulation may be considered
(IIb, C) (only by experienced operators at
restricted HT centers).

70. Conclusion
•
•
•
•
Patients with DM & CKD require more aggressive BP
control.
Most patients with hypertension will require two or
more antihypertensive medications to control blood
pressure.
The use of combination therapy is appropriate as
initial treatment.
Sustained antihypertensive efficacy may protect
against the early morning rise in blood pressure that
leads to heightened risk of cardiovascular events.

71. THANKS